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SAN JOARIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r'Lv�s �-►9 nsT o7(a DJ Q,9, c6 776ba <br /> OWNER I OPERATOR I`Lt1/ttiI ,A <br /> IVv' 4J�}f'nG 'r�'.r/Jr• I CHECK If BILLING ADDRESS <br /> FACILITY NAME ) / .,�� V <br /> f <br /> SITE ADDRESS <br /> str¢e[Number iI DIirectlan l/� N�v B'35� —T <br /> Street Nama CI ZI Cotle <br /> CAJ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) '7 07'2,i /'r <br /> treet Number (�f(•(J C�/�St/ravee NlamLaTv /L+/./ <br /> CITY ST E zip 9q-9 3 <br /> PHONE#t EXT' APN# LAND USE APPLICATION# /7 <br /> (91s> 9g —1 9 to i -071 q <br /> PHONE#2 EXT• BOS DISTRI LOC ION CODE <br /> ( ) <br /> CONTRACT / SERVICE RE <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME A ) P lo# <br /> HOME or MAILING ADDRESS ,^ , 'n 1 /` FAX III <br /> CITY CA— STATE CAzip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and GeR s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERAT .MAN GER ❑ OTHER AUTHORIZED AGENT /I/L.C.yf //[/✓� <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign Is require Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to me or <br /> my representative. <br /> a✓I erg— Ay"MM " <br /> TYPE OF SERVICE REQUESTED: '' �p91 Gadd`.u�i <br /> COMMENTS: RECEIVED <br /> � hr C-McK- J V,! U 6 2097 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY:� /!"l EMPLOYEE DATE: ./_ 1-7 <br /> ASSIGNED TO: I �` EMPLOYEE#: DATE: V/ <br /> Date Service Comple (if already completed): SERVICE CODE:G. PIE::: / <br /> Fee Amount:a -7oo Amount Paid a7 g U Payment Date <br /> Payment Type C Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />